Improving AV Fistula and Graft Cannulation Practice MAGIC: A National KQuIP Project Katie Fielding, MAGIC Lead and Co-Chair BRS VA Senior Clinical Educator Haemodialysis, RDU Derby Chair, Measurement & Understanding Workstream, KQuIP
KQUIP: KIDNEY QUALITY IMPROVEMENT PARTNERSHIP Paul Cockwell, Co Lead, KQuIP Consultant Nephrologist, Birmingham QEH Professor, University of Birmingham Clinical Vice President, Renal Association
CHALLENGES OF CANNULATION PRACTICE
Discussion 1) What is good about your cannulation practice? 2) What would you like to improve in cannulation practice? 3) What do you think is the consequence of poor cannulation practice?
CANNULATION BEST PRACTICE
BRS VA and V Cannulation Recommendations Being released later this year Incorporates: Buttonhole, rope ladder and area puncture cannulation AV grafts and fistulae Paeds and adults Existing BH recommendations A good needling technique will: Minimise damage to the AV fistula / graft during needling Minimise complications from needling Minimise pain and anxiety related to needling
How to Cannulate Well How to insert the needle well Gentle and considered insertion Sure of direction and depth Balance of empathy and necessity Technical aspects Needle gauge Needle direction and depth Procedural aspects Infection control Taping
Pre-Cannulation Assessment
Cannulation Techniques
Choosing your Cannulation With patients Techniques Length of cannulation segment Infection risk Screening tool (Swain et al, 2017) Needle phobia Ease of cannulation
How to Avoid Area Puncture Avoid if possible Educate patients Educate staff Needling plan Maybe a necessary evil Monitor for complications
Managing Anxiety related to Cannulation Used paediatric expertise Requires attention in adult setting Tendency to ignore Requires further research Desensitisation Handling the needle Using the needle Music Breathing control Control of procedure Time Calm environment
Patient Involvement Involve patient s in their VA care Adult participants Not telling what to do Involvement is more than setting up their pack and selfcannulation Include in all decisions Starts pre-dialysis View needling and VA care as a partnership Encourage self needling Support required to self-needle
Other Sections How to do Buttonhole well Track development Disinfection prior to cannulation Use of mupirocin on needle sites Summary of rope ladder procedure Use of nurse-led US assessment Cannulating new AVF / G
MANAGING ACCESS BY GENERATING IMPROVEMENTS IN CANNULATION (MAGIC)
MAGIC Quality Improvement project Designed by BRS VA and V nurses KQuIP supporting the implementation Regional implementation Implementation of Cannulation Recommendations Aim: To improve prevalent AVF/G rates: Improve cannulation to preserve AVF/G function Make AVF/G more attractive through better patient experience Develop structures to support further VA QI
Elements of MAGIC Leadership Measurement Needling Champion - Nurse Monthly clinical outcomes Materials Run Charts Nephrologist Measure impact Guide future QI ELearning based on Recommendations Awareness materials for patients
Leadership Nurse lead and nephrologist lead Developed through KQuIP training Work together Meet monthly Lead MAGIC locally Regional MAGIC network Meet 3 monthly Continue doing QI following MAGIC
Measurement Core measurement strategy Flexible local additions Monthly local audit Collected by needling champion Life QI Run charts / Trends Compare Before / after Regionally Sample of Patients Needling technique Missed cannulation Patient experience of cannulation PREM needling question Whole Unit No. AVFs used for HD No. of AVFs lost No. new AVFs used Infection
Implementing MAGIC Leaders Training Baseline Measures Training Day 1 - KQuIP Phase 1 ELearning Training Day 2 KQuIP Phase 2 Awareness Materials Training Days 3 KQuIP Phase 3 Region designed Celebration event and further QI MAGIC Network (3 monthly) + Monthly Measures
Website - www.thinkkidneys.nhs.uk/kquip/magic/ Facebook - www.facebook.com/groups/1918050308446120/ Twitter - twitter.com/haemodialysisva